Milan Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure facility staff provided six residents (Resident #3, #11, #30, #33, #54 and #79), of 24 sampled residents that were unable to perform their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 98. Review of the facility's policy for ADLs, revised on 05/18/24, showed the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for bathing, dressing, grooming, toileting and oral care; -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's policy for Peri-Care, revised on 06/29/23, showed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for five residents (Resident #33, #54, #29, #11 and #30) in a review of 24 sampled residents. Staff failed to provide routine showers to ensure good personal hygiene, failed to provide restorative nursing to prevent decline in Activities of Daily Living (ADL's) and new or worsening contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The facility census was 98. Review of the Facility Assessment, dated 08/04/24, showed the following: -Federal regulations will require that facilities must provide 3.48 hours per resident day (HPRD) of direct care with 0.55 HPRD from registered nurses (RNs) and 2.45 HPRD from nurse aides (Certified Nurse Assistants (CNAs), Nurse Aides (NAs), or medication technicians/aides); -The remaining 0.48 HPRD can be a combination of nurse staff (RNs, Licensed Practical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow policy to check temperatures during the meal service and failed to serve food items in a manner to ensure the food was at a safe and appetizing temperature. The facility census was 98. Review of the facility's policy, Receiving and Storing Food and Supplies, last revised 6/30/23, showed the following: -Record reading on Food Temperature Chart form at beginning of tray line and during the tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving; -Acceptable serving temperatures are: casseroles (greater than 135 degrees Fahrenheit); hot pureed food (greater than 135 degrees Fahrenheit); hazardous salads and desserts (less than 41 degrees Fahrenheit). 1. During an interview on 03/02/25 at 6:05 P.M., Resident #43 said he/she sometimes ate in the dining room and sometimes ate in his/her room. The food was not very warm when served. During an interview on 03/02/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nursing staff washed their hands after each direct resident contact and between glove changes, for three residents (Resident #3, #33, #79) of 24 sampled residents, failed to ensure soiled surfaces were sanitized appropriately, failed to ensure proper infection control was utilized for respiratory care supplies for one resident, (Resident #7), and failed to wear gloves when administering eye drops for one resident (Resident #25). The facility census was 98. Review of the facility policy, Hand Hygiene, revised on 06/26/24, showed the following: -Purpose: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility; -Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); - Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had the right to be as independent as possible when one resident (Resident #30), in a review of 24 sampled residents, who required a power wheelchair to be fully independent with mobility, was denied the assistance in obtaining a power wheelchair. Resident #30 was told by the administrator she forbid power chairs at the facility because they could hurt someone and that he/she would need to move to another facility if he/she wanted a power chair. The resident felt hopeless and discriminated against. Resident #11 had a power wheelchair, but said the administrator had threatened to take it away. The administrator said the resident failed his/her driver test and she was looking to take the resident's chair as she did not want any motorized chairs in the building. The resident's medical record showed no documentation the resident had failed his/her driving test. The threat of having the chair taken away made the resident feel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide restorative nursing services to assist two residents (Resident #30 and #55), in a review of 24 sampled residents, in attaining or maintaining their highest level of functioning. The facility failed to follow their policy to develop restorative plans with the problem, needs/strengths, measurable goals with a target date, specific interventions/task to be provided, frequency and duration of interventions/task, such as number of repetitions, length of time, or direction to staff to meet resident needs. The facility census was 98. Review of the facility policy, Restorative Nursing Program (RNP), dated 04/30/24, showed the following: -It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level; -Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report an allegation of sexual abuse involving two residents (Resident #1 and #2), in the review of six sampled residents to the state agency. The facility census was 94. Review of the facility Abuse and Neglect policy, last revised 06/12/2024, showed the following: - It is the policy of the facility to report all allegations of abuse are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within the prescribed time frames; -Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to, the following: -Unwanted intimate touching of any kind especially of breasts or perineal area (the area of the body between the anus (rectal opening) and the external genitalia-the male or female reproductive organs); -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -This also includes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents (Resident #1 and #2), of six residents sampled residents. The facility did not complete resident interviews with other residents following the incident to assess if they felt safe or had been subjected to or witnessed abuse and did not interview all staff present at the time of the alleged incident of abuse. The facility census was 94. Review of the facility Abuse and Neglect policy, last revised 06/12/2024, showed the following: -Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to, the following: -Unwanted intimate touching of any kind especially of breasts or perineal area (the area of the body between the anus (rectal opening) and the external genitalia-the male or female reproductive organs); -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -This also includes failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff safely secured one resident (Resident #1), in a review of six residents, in the facility van during transport. The facility census was 93. On 10/2/24 at 11:25 A.M., the administrator was notified of the past noncompliance which occurred on 9/11/24. Upon notification of the incident, the facility completed an investigation and notified appropriate parties. The facility reeducated the transportation staff how to safely secure residents in the transport van. The deficiency was corrected on 9/11/24. During an interview on 10/1/24 at 11:15 A.M., the administrator said the facility did not have a policy for how to safely secure a resident in the transport van. 1. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/24/24, showed the following: -Severely impaired cognition; -Required moderate assistance of staff for transfers; -Used a wheelchair for mobility; -Diagnosis frontotemporal neurocognitive disorder (group of brain diseases that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect two residents' (Resident #1 and #2's) of six sampled residents, right to be free from sexual abuse. The facility had not assessed either resident for capacity to consent to sexual contact when staff observed the residents touching, kissing and fondling each other. Resident #2 had a history of hypersexual behavior, was under guardianship and cognitively impaired. Resident #1 was under guardianship and had severely impaired cognition. On 4/28/24, staff found the residents without clothing and in bed together with physical indications the residents had been sexually intimate. The facility census was 89. Review of the facility policy and procedure, Sexual Activity/Abuse and Neglect, dated (origination) 4/6/2017, and last reviewed/revised 4/18/22, showed the following: -The purpose of this policy is to ensure that the facility provides protective oversight and care for all residents requesting to engage in sexual activity/intercourse while at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY ar reviewing Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents (Resident #1 and #2) of six sampled residents. The facility's investigation did not include interviews with other residents following the incident to assess if they felt safe or had been subjected to or witnessed abuse, and did not inteview all staff present at the time of the alleged incident of abuse. The facility census was 89. Review of the facility Abuse and Neglect policy, dated (origination) 11/28/2016 and last reviewed/revised 04/30/2024, showed the following: -Purpose: To outline procedures for reporting and investigating complaints of sexual abuse, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designees and the Director of Nursing or designee and outside persons or agencies. To establish…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of discharge with the required information to the resident and/or resident representative for one resident (Resident #3), in a review of seven sampled residents. The facility initiated a transfer to the hospital, denied the resident readmission to the facility and did not find appropriate placement for the resident. The facility census was 89. Review of the facility Resident Transfer/Discharge Written Notification Policy and Procedure, dated [DATE], showed the following: -If a resident was transferred with the expectation of returning to the facility and the resident cannot return to the facility, the facility must follow the requirements for a discharge; -If you do not agree with the facility's decision to discharge you/your ward, you have the right to file an appeal on this notice to the Administrative Hearings Unit within 30 days of notice. 1. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to efficiently utilize staff to serve meal trays timely. Residents sat from 45 minutes to over two hours awaiting their meals. The census was 93. Review of the facility's meal times (provided by the facility), dated 06/05/23, showed the following: -Breakfast at 7:00 A.M.; -Lunch at 12:00 noon; -Supper at 5:00 P.M.; -100/200/400 hall hot cart after dining room; -300 hall hot cart after dining room at breakfast and lunch and before dining room at supper. 1. During an interview on 06/06/23 at 7:45 A.M., Resident #68 said he/she has to wait over one hour to get his/her breakfast. Residents have to sit and wait for one to two hours for supper. During an interview on 06/06/23 at 9:21 A.M., Resident #26 said he/she would like to have drinks while waiting for meals as it takes a long time (1 1/2 to 2 hours); During an interview on 06/06/23 at 11:16 A.M., Resident #50 said residents arrived in the dining room for lunch at noon, and staff didn't start serving food until 12:45 P.M. It was 2:30 P.M. or 2:45 P.M. before all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure meals were served to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the diet spreadsheet menu. Staff also failed to prepare food items in accordance with facility recipes and failed to serve residents the appropriate portion sizes of food items as indicated on the spreadsheet menu. The facility census was 93. Review of the facility policy, Dietary Food Preparation, revised 4/9/21, showed the following: -Standardized recipes will be used for all products prepared; -Use standardized recipes provided with menu cycle; -Standardized recipes will be adjusted for therapeutic and consistency modifications; -The Dietary Manager will monitor and check routinely the cooks' use of recipes. If favorite recipes are added to the recipe file, they must be written, standardized and approved by the Registered Dietician; -Recipes have diet modifications noted; -Pureed recipes are found in the Recipe Binder; -The dietary department will ensure that food is prepared in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide food and drink items at a safe and appetizing temperature. The facility census was 93. Review of the facility policy, Dietary Food Preparation, revised 4/9/21, showed the following: -Foods will be served at proper temperature to ensure food safety; -Procedure: Record temperature reading on Food Temperature Chart form at beginning of tray line and during the tray line; -Take the temperature of each pan of product before serving; -If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature; -Acceptable serving temperatures are: -Meat, entrees: greater than 135 degrees Fahrenheit (F), but preferably 160 to 175 degrees F; -Hot pureed foods: greater than 135 degrees F, but preferably 160 to 175 degrees F; -Hazardous salads and desserts: less than 41 degrees F; -Milk, juice: less than 41 degrees F; -If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution and discard…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Staff failed to properly thaw potentially hazardous foods in order to prevent spoilage. Staff failed to monitor for and maintain appropriate holding, storage, and serving temperatures for hot and cold food items. Staff failed to discard food that was expired or showed visible signs of deterioration, failed to store and handle food products to maintain quality and free from potential contaminants, failed to store food products separately from cleaning products, and failed to label and date opened food items. The facility also failed to ensure sanitary practices in the kitchen when staff failed to ensure food tableware and beverage containers were protected from moisture, debris, and other contaminants and kitchen surfaces and equipment, such as refrigerators, freezers, fans, vents, walls, floors, ceilings, cooking appliances, were clean and maintained to prevent potential contamination. Staff also failed to ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop specific control parameters for addressing Legionella (a bacterium that can cause a serious type of pneumonia in persons at risk), based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards and failed to complete a facility assessment. The facility did not have a water management team, detailed water flow map, and did not implement the facility's Legionnaire Disease (severe pneumonia like infection caused by contaminated water) policy that instructed staff how to monitor residents for Legionnaire's disease. The facility also failed to clean glucometers as directed by manufacturer's instruction between residents for one resident (Resident #18), and two additional sampled residents (Resident #39 and #46). The facility failed to clean the rubber stopper on insulin vials, pens, and the administration site for one resident (Resident #18), and failed to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three residents (Resident #49, #59, and #89), in a review of 23 residents and two additional sampled residents (Resident #410 and #411), were treated with dignity and respect when staff refused to provide assistance, and verbalized rude and disrespectul responses to residents. The facility census was 93. Review of the facility's policy, Dignity and Respect, revised 07/09/2021, showed the following: -Purpose to ensure that every resident is treated with dignity and respect; -Every resident has a right to be treated with dignity and respect; -All staff will speak to and treat all residents with dignity and respect. 1. Review of Resident #89's face sheet showed his/her diagnoses include major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a mental health disorder characterized by feelings…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to check the Family Care Safety Registry (FCSR) or a Criminal Background Check (CBC) prior to the hiring of five employees (Registered Nurse (RN) N, the Assistant Dietary Supervisor, the Laundry Aide, the Maintenance Assistant and the Transportation staff) in a review of ten employees hired since the previous annual survey, failed to conduct an Employee Disqualification (EDL) check for any Federal Indicators of abuse, neglect, or misappropriation of property for one employee (RN N) and failed to conduct a Certified Nurse Aide (CNA) Registry check for two employees (RN N and the Maintenance Assistant). The facility census was 93. Review of the facility policy, Pre-Employment Screening,revised 5/9/22, showed the following: -Human Resources department (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any Federal or State healthcare programs, is eligible to work in the United States, and, if applicable, is duly licensed or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written notice of transfer/discharge to the resident and/or resident representative when three residents (Residents #48, #49 and #394), in a review of 23 sampled residents, were transferred to the hospital. The facility did not provide any other written documentation to the resident or resident representative of the reason and date for transfer/discharge, where the resident was transferred/discharged , ombudsman contact information, information on how to appeal a transfer/discharge, or how to contact the mental health advocacy group for residents with intellectual disabilities or mental illness. The facility census was 93. Review of the facility's policy Resident Transfer / Discharge, Immediate Discharge, and Therapeutic Leave , revised 07/12/22, showed the following: -Transfer and Discharge: Includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. -Discharge After…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility for four residents (Resident #80, #89, #91 and #394) in a sample of 23 residents. The facility failed to provide a copy of the baseline care plan to the resident/resident representative for six residents (Resident #80, #89, #91, #93, #394 and #24). The facility census was 93. Review of the facility policy, Baseline Care Plan Rules, revised 01/19/22 showed the following: 1. The electronic medical record (EMR) care plan section has a baseline care plan library that you may choose from but you must individualize the plan of care for each resident; 2. All baseline care plan must be completed within 48 hours of admission. 3. The Baseline Care Plan must consist of the following resident information: Allergies,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure five nurse aides (NA B, NA C, NA D, NA E and NA F ) completed a nurse aide training program within four months of their employment in the facility. The facility census was 93. During an interview on [DATE], at 3:11 P.M., the Director of Nursing (DON) said the facility did not have a policy on certification of nurse assistants. Review of the facility staff title listing, dated [DATE], showed the following: -Facility hired NA B on [DATE] as a NA; -Facility hired NA C on [DATE] as a NA; -Facility hired NA D on [DATE] as a NA; -Facility hired NA E on [DATE] as a NA; -Facility hired NA F on [DATE] as a NA. 1. Review of NA B's employee file showed he/she was hired [DATE] as a NA. The employee file showed no documentation NA B completed a nurse aide training program within four months of his/her hire date. 2. Review of NA C's employee files showed the following: -He/She was hired [DATE] as a nurse assistant; -On [DATE], job title was changed to hall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure proper administration of physician ordered insulin via an insulin pen for two sampled residents (Resident #18, and #50), and two additional residents (Resident #71 and Resident #52) by not holding the insulin pen in place for the appropriate amount of time per policy and per themanufacturer's instructions. Failure to follow procedure for adminsitration results in residents not recieving the ordered dose of insulin. The facility census was 93. Review of the facility policy Insulin and Insulin Pen Skill Competency Test undated showed the following: 1. Check for the Five Rights a. Identifies the correct time. b. Verifies medicine container matches the Medication Administration Record. c. Verifies the dose on medication container matches MAR. d. Verifies the medication is in the correct route identified on the MAR. 2. Check expiration date of insulin pen/vial. a. Check to see if the insulin cartridge is loaded into insulin pen. If not,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents with a physician order for a mechanical soft diet received food items with the proper texture and gravy/sauces to allow for foods to be easily swallowed. The facility census was 93. Review of the facility policy, Dietary Food Preparation, revised 4/9/21, showed the following: -Standardized recipes will be used for all products prepared; -Procedure: -Use standardized recipes provided with menu cycle; -Standardized recipes will be adjusted for therapeutic and consistency modifications; -The Dietary Manager will monitor and check routinely the cooks' use of recipes; -Recipes have diet modifications noted. 1. Review of the Diet Orders, printed 06/05/23, showed 16 residents with a physician-ordered mechanical soft diet (with mechanical soft meat). Review of the Diet Spreadsheet, for Lunch Day 2, Monday (06/05/23), showed residents with mechanical soft diet orders were to be served ground meatballs with gravy (#8 dip) and sauce (2 ounces). Review of the recipe binder showed the following: -Ground…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet when staff failed to serve replacement food items that ran out during the meal service, and failed to serve appropriate food substitutes to honor resident preferences. The facility census was 93. Review of the facility's policy, Accommodation of Needs, revised 10/12/21, showed the following: -Reasonable accommodations will be made by the Dietary Department to those residents with food preferences. A food preference inventory will be conducted during the Initial Nutritional Screen by the Dietary Manager. -Substitutes of like calorie value will be offered to the resident if the planned menu is refused. If the resident refused the nutritional substitute, a menu of like caloric value will be offered. 1. During interview on 06/06/23 at 11:16 A.M. Resident #50 said the following: -For dinner on 06/05/23, he/she was looking forward to eating the white chicken chili but it ran out and he/she received a slice of bologna on two pieces of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide drinks to residents who preferred to have drinks while waiting for their meals in the dining room. This affected seven residents (Resident #68, #26, #84, #17, #23, #59, and #145) The facility census was 93. Review of the facility policy Nutrition-Hydration Protocol, dated 6/7/23, showed residents will be provided sufficient fluid intake to maintain hydration and health. During interview on 6/6/23 at 7:45 A.M., Resident #68 said he/she would like to have drinks while awaiting meals as he/she had to sit so long. He/She has to wait over an hour in the morning to get any coffee. Residents have to sit for one to two hours for supper with no drinks. During interview on 6/6/23 at 9:21 A.M., Resident #26 said he/she would like to have drinks while waiting for meals since it took a long time (to get his/her meal). Observations and interviews in the dining room on 6/6/23 showed the following: -At 12:00 P.M., observation showed many residents sat at tables in the dining room without drinks; -At 12:10 P.M., Resident #84 said…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately code section G Functional Status of the Minimum Data Set (MDS), a federally required assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for two sampled residents (Resident #13 and #18) in a review of 23 sampled residents. The facility census was 93. Review of the CMS's RAI version 3.0 Manual, dated October 2019, showed the following: -Coding Instructions for G0110, Column 1, Activity of Daily Living (ADL) Self-Performance: -Code 0, independent if resident completed activity with no help or oversight every time during the 7-day look-back period and the activity occurred at least three times; -Code 1, supervision if oversight, encouragement, or cueing was provided three or more times during the last 7 days; -Code 2, limited assistance if resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight-bearing assistance on three or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow professional standard of care for two residents (Resident #71 and #84), in a review of 23 sampled residents, when staff failed to follow physician's orders for treatments. The facility census was 93. Review of the facility policy, Transcription of Orders/Following Physician's Orders, revised 07/09/21, showed all physician orders should be followed. Review of the facility policy, Medication Administration and Monitoring, revised on 09/17/21, showed the following: -Medications are to be given per physician's orders; -Watch the resident take the medication. 1. Review of Resident #71's face sheet showed the resident's diagnoses included diabetes mellitus (too much sugar in the bloodstream) and cellulitis of unspecified part of limb (a common and potentially serious bacterial skin infection). Review of the resident's June 2023 physician order sheet showed an order for Mupirocin 2% ointment (an antibiotic ointment used to treat skin infections), apply to left heel every day shift for open area. Cleanse with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain good oral hygiene for one resident, (Residents #64), in a review of 23 sampled residents, who took no fluids or nutrition in by mouth (NPO) and required assistance to perform their activities of daily living (ADL). The facility census was 93. Review of the facility policy, Oral Care, revised 03/25/2022, showed residents should all receive good oral hygiene. The facility did not provide a policy for addressing oral care in residents who were not able to to receive anything by mouth, (NPO). 1. Review of Resident #64's face sheet showed diagnoses including traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), epilepsy (seizure disorder), encephalopathy (a brain disease that alters brain function or structure) and malignant neoplasm of brain (a fast growing cancer that spreads to other areas of the brain and spine). Review of the resident's care plan, revised on 02/02/23, showed the following:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain the services of a Speech Therapist (ST) for one sampled resident (Resident #90) out of 23 sampled residents and one additionally sampled resident (Resident #73) or obtain testing needed for ST to evaluate residents for appropriate diets. The facility census was 93. Review of the facility's policy Physician's Orders for Therapy, dated 1/19/22, showed the following: -All admissions, re-admissions and changes in functional status, that require therapeutic intervention will be screened for therapy services; -When evaluation and treatment orders are obtained by the Director of Nursing/Designee or MDS Coordinator, they will be transcribed to the Physician's Orders; -The therapy recommendations will be reviewed by the Administrator and Director of Nursing. Only after the Licensed or Registered Nurse receives Physician's orders (therapy clarification orders) designating the type of therapy (Physical Therapy, Occupational Therapy and Speech Therapy),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to complete required employee background screenings by failing to provide documentation of criminal background checks (CBC), employee disqualification list (EDL) checks, and/or nurse aide registry checks completed prior to employment for four of ten newly hired employees reviewed. The facility census was 92. 1. Review of the facility's policy and procedure (undated) on pre-employment screening, showed the following: -Human Resources (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any federal or state healthcare programs, is eligible to work in the United States, and, if applicable, is duly licensed or certified to perform the duties for which they applied; -A criminal background check should be done through the Missouri Highway Patrol's Missouri Automated Criminal History Site. A copy of the results must be printed with the original initialed and dated by the person who conducted the check; -If a check is made through the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to design an activity program to meet the needs, interests, physical, mental and psychosocial well being for one resident (Resident #52) in a review of 19 sampled residents and six additional residents (Residents #47, #27, #5, #32, #30 and #91). Staff failed to ensure weekend activities were provided for residents in the locked units. The facility census was 92. 1. Review of the facility's undated policy, Activities, showed the following: -The purpose of the polity is to ensure all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with comprehensive assessment, their interests and their physical, mental and psychosocial well-being; -To ensure an ongoing program of activities is designed, the life enhancement director will monitor large and small group activities, one-on-one programming and self-directed activities. The life enhancement director will modify the care plan interventions to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure the residents' environment on the locked mens' unit was maintained to be in good repair, clean and homelike. The census was 92. 1. Review of the facility policy Environmental Rounds revised 4/6/2017 showed the following: -To ensure the safety of all residents and staff within the unit; -Environmental rounds are to be done daily by the Department Heads; -The Department Head should be inspecting the room for potentially hazardous items and any areas that may not be in compliance of state and federal regulations. Observation on 10/6/19 at 1:03 P.M. in the locked mens' unit showed the following: -The dining room was painted lime green in color. There were multiple white patches on the green paint; -A torn cove base on wall under light switch by dining room door; -No cove base along floor beside sink area in dining room; -Multiple cracks in the ceiling in the dining room; -Dining room floor scuffed and soiled with brown black debris; -Multiple nicks and gouges on the window frame in the dining room; -Gray vinyl wall board…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.